⚡ Severe Hypo/Hyperglycaemia in Pregnancy
1 RECOGNIZE
- Hypoglycaemia: glucose <4 mmol/L (72 mg/dL); severity is determined by impaired consciousness/need for assistance, not only a <54 mg/dL threshold.
- DKA: ketonaemia/acidosis in a patient with diabetes or hyperglycaemia; pregnancy DKA can occur with only modest or normal-range glucose. Measure ketones and VBG when unwell, vomiting or breathless.
2 CALL FOR HELP
- Urgent obstetric and diabetes/medical review; DKA, impaired consciousness or haemodynamic compromise requires HDU/ICU capability.
3 IMMEDIATE ACTION
- HYPO, awake and safe swallowing: give 15–20 g rapid carbohydrate and recheck after 10–15 min; repeat if still low. If unconscious/unsafe swallowing, give IV glucose or IM glucagon using the exact cards below; never give oral fluids.
- DKA: begin monitored isotonic fluid replacement, insulin and electrolyte management with the medical/obstetric team. The usual adult first 1 L over 1 h requires adaptation in pregnancy, cardiac/renal disease or shock; reassess perfusion and fluid tolerance rather than simply prescribing “first litre fast”.
- Use SOLUBLE insulin at the stated concentration/rate, not NPH or a pen formulation IV. Measure potassium before and repeatedly during insulin; add glucose early for euglycaemic DKA or when glucose <14 mmol/L.
- Continue prescribed basal insulin unless the specialist team changes it. Identify infection, missed insulin, vomiting, steroid exposure or pump failure.
Drug doses & preparation
Choose the regimen for the stated indication. Alternatives are not instructions to give every medicine. Check prior doses, contraindications, concentration and the response before repeating.
Glucose — severe hypoglycaemiaJBDS-IP / ABCD / Diabetes UKchecked
Dose20 g glucose: 200 mL of 10% OR 100 mL of 20% solution
RouteIV infusion
FrequencyGive over 10–15 min; recheck glucose at 10 min and repeat if still <4 mmol/L with reassessment
DurationAcute rescue followed by longer-acting carbohydrate when awake and safe to swallow, or prescribed ongoing infusion
Preparation10% =100 mg/mL; 200 mL =20 g. 20% =200 mg/mL; 100 mL =20 g. Check IV patency and use a limited volume so a whole large bag cannot infuse accidentally
Max doseReassess after each 20 g treatment; recurrent/prolonged hypoglycaemia needs monitored ongoing treatment
- Indication: Impaired consciousness or unsafe swallowing; never give oral fluid to an unconscious patient
Monitoring
- Glucose 10 min after treatment, then serially until stable; consciousness, swallow and IV site
- Identify missed food, insulin excess, renal failure or infection; do not omit basal insulin in type 1 diabetes
Contraindications: Do not give oral sugar when swallowing is unsafe; hypertonic glucose extravasation can injure tissue
Dose1 mg
RouteIM
FrequencyOne rescue dose; obtain IV access and recheck glucose after 10 min
DurationBridge to reliable glucose delivery; give carbohydrate after recovery
PreparationReconstitute the 1 mg vial with its supplied solvent immediately before IM use; verify final dose
Max dose1 mg initially; repeated glucagon may be ineffective and must not delay IV glucose
- Indication: Severe insulin-associated hypoglycaemia when IV access is unavailable
Monitoring
- Consciousness, glucose and nausea/vomiting; replenish carbohydrate once swallowing is safe
Contraindications: Reduced effectiveness with prolonged starvation, liver disease, depleted glycogen or repeated episodes
Soluble human insulin — DKAJBDS-IP / Diabetes UKchecked
Dose0.1 units/kg/hour IV; no routine IV insulin bolus. Consider 0.05 units/kg/hour once glucose <14 mmol/L alongside glucose infusion
RouteIV infusion pump
FrequencyContinuous with hourly response-based review
DurationContinue until ketones <0.6 mmol/L AND venous pH >7.3, clinical recovery and safe transition; not merely until glucose normalises
PreparationUsing U-100 SOLUBLE insulin: 50 units =0.5 mL; add to 49.5 mL sodium chloride 0.9% for FINAL 50 mL =1 unit/mL. At 0.1 units/kg/h, 70 kg =7 units/h =7 mL/h. NEVER use cloudy NPH IV
Max doseNo universal fixed hourly ceiling; inadequate ketone fall needs line/pump and dose reassessment. Potassium <3.5 mmol/L requires urgent senior-led replacement and insulin review
- Indication: Pregnancy DKA, including euglycaemic DKA; urgent monitored obstetric/diabetes care
Monitoring
- Hourly glucose and blood ketones; frequent VBG, potassium and electrolytes; target ketone fall ≥0.5 mmol/L/h
- Add 10% glucose at 125 mL/h when glucose <14 mmol/L; euglycaemic pregnancy DKA may require glucose from the start
- Continue usual long-acting basal insulin unless specialist contraindication; overlap IV insulin for 30–60 min after the appropriate subcutaneous meal dose during transition
Contraindications: Severe hypokalaemia, shock, renal/cardiac disease require immediate specialist adaptation; never prescribe insulin without a fluid/potassium plan
4 INVESTIGATIONS (never delaying treatment)
- Hourly glucose and blood ketones; VBG/pH/bicarbonate, potassium/electrolytes, renal function and ECG; initial repeat electrolytes at least at 1 and 2 h, then according to clinical course.
- Cultures/other precipitant tests when indicated; monitor fluid balance and fetal condition at a gestation where monitoring informs care.
5 DEFINITIVE MANAGEMENT
| Potassium | Action |
|---|---|
>5.5 mmol/L | No potassium in the initial replacement fluid; recheck as treatment rapidly lowers potassium. |
3.5–5.5 mmol/L | If passing urine and renal status permits, usual replacement is premixed potassium 40 mmol/L in resuscitation fluid; account for the infusion rate and repeat levels. |
<3.5 mmol/L | Urgent senior/critical-care review for additional replacement and an insulin plan. Do not continue an unreviewed insulin prescription; concentrated potassium requires the appropriate monitored setting. |
Any potassium infusion | Never IV push potassium; use premixed/approved dilution and a labelled pump under the hospital policy. |
- Continue IV insulin until ketones <0.6 mmol/L AND venous pH >7.3 with clinical recovery; glucose correction alone does not mean DKA has resolved.
- When eating and transitioning safely, give the appropriate subcutaneous insulin and overlap IV insulin for 30–60 min. Confirm the basal regimen and prevent another missed-insulin interval.
- Abnormal fetal monitoring may improve with maternal correction; do not make automatic delivery the treatment for DKA without an obstetric indication.
6 ESCALATION
- Shock, severe acidosis, altered consciousness, hypokalaemia, respiratory compromise or failure of ketones to fall: critical-care/diabetes reassessment immediately.
7 POST-EVENT CARE
- Review the precipitant and prescribe an explicit insulin plan, ketone/sick-day instructions and hypoglycaemia rescue plan.
- Arrange diabetes and obstetric follow-up; verify access to insulin, meters/strips/CGM and ability to use them.
Admission & discharge after the acute event
Care setting: Outpatient coordinated care when stable; hospital admission for DKA or severe hypoglycaemia
Admission/discharge guidance checked 2026-10-18 against the linked sources. This is a clinical checklist for an individual decision, not an automatic discharge order.
When admission or continued hospital care is needed
- Suspected DKA in pregnancy requires urgent hospital/critical-care assessment even when glucose is not extremely high. Admit severe/recurrent hypoglycaemia, inability to maintain intake or maternal/fetal compromise.
When clinic, day care or home care may be suitable
- Stable type 1/type 2 diabetes needs joint obstetric/diabetes follow-up, not routine inpatient care.
Before going home
- DKA resolution includes blood ketones <0.6 mmol/L and venous pH >7.3, clinical recovery and a safe insulin transition; normal glucose alone does not establish resolution.
- Eating/drinking and glucose/electrolytes are stable; subcutaneous insulin has been given with the required overlap and specialist review. After hypoglycaemia, the cause/recurrence risk has been addressed.
Discharge medicines and treatment changes
- Never stop all insulin in type 1 diabetes. After birth reduce insulin through an individual written plan with frequent glucose review; the GDM stopping rule does not apply.
- Provide insulin, delivery devices, glucose/ketone strips and prescribed rescue treatment; teach the patient/family what to do when unwell.
Medicine doses — use only when indicated
Use the medicines selected for this patient. Listed alternatives are not instructions to prescribe all of them together. Confirm the actual remaining course, pregnancy/postnatal context and monitoring plan.
Rescue treatment when specifically prescribed with patient/family training.
Dose1 mg
RouteIM
FrequencyOne rescue dose; obtain IV access and recheck glucose after 10 min
DurationBridge to reliable glucose delivery; give carbohydrate after recovery
PreparationReconstitute the 1 mg vial with its supplied solvent immediately before IM use; verify final dose
Max dose1 mg initially; repeated glucagon may be ineffective and must not delay IV glucose
- Indication: Severe insulin-associated hypoglycaemia when IV access is unavailable
Monitoring
- Consciousness, glucose and nausea/vomiting; replenish carbohydrate once swallowing is safe
Contraindications: Reduced effectiveness with prolonged starvation, liver disease, depleted glycogen or repeated episodes
Tests, pending results and their reviewer
- Review renal/electrolyte results after an acute event and record retinal/renal follow-up; glucose logs/CGM do not replace clinical review of recurrent lows.
Home care and counselling
- Give sick-day and hypoglycaemia instructions, out-of-hours contacts, feeding-related hypo precautions and the exact pre-birth/post-birth insulin plan.
Follow-up: when and what to review
| When | Action / responsible service |
|---|---|
Before discharge after DKA/severe hypoglycaemia | Diabetes-team review, education and a booked early contact; document the precipitating cause and prevention plan. |
Within the existing joint pregnancy follow-up schedule / immediately after birth | Review glucose and doses promptly after treatment or physiological changes; do not wait for a routine 6-week check to adjust insulin. |
Return urgently
- Vomiting, ketones, dyspnoea, confusion, inability to maintain intake or severe/recurrent low glucose requires urgent hospital care.
Open the complete discharge checklist →
Sources for this plan:
Sources
JBDS-IP / ABCD / Diabetes UKcheckedJBDS-IP / Diabetes UKcheckedNICE · NG3checkedNICE · NG194, recommendationscheckedIndia MoHFW / NHM · LaQshya district-hospital SOP, linked editioncheckedWHO · 2022 official recommendation summarycheckedRCOG · Current public recovery informationcheckedNICE · CG50, recommendationschecked